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The importance of contractile reserve in predicting exercise tolerance in asymptomatic patients with severe aortic stenosis

Echo Research & Practice volume 6, pages 43–52 (2019)Cite this article

Abstract

Background Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.

Methods Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.

Results Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO2peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S′) and age were the strongest independent predictors for VO2peak (R2 = 0.76; P < 0.0001). Exercise S′ was the strongest independent predictor for NT-ProBNP (R2 = 0.48; P = 0.001).

Conclusion A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S′ on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.

References

  1. Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. Journal of the American College of Cardiology 2006 47. (https://doi.org/10.1016/j.jacc.2006.03.002)

  2. Boasi V, Casale MC, Aste M, Tarantini G, Gallina S, Balbi M, Brunelli C, Bezante GP. Aortic stenosis in the elderly: understanding the new therapeutic options. World Journal of Cardiovascular Surgery 2012 2. (https://doi.org/10.4236/wjcs.2012.24019)

  3. Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G. Natural history of very severe aortic stenosis. Circulation 2010 121. (https://doi.org/10.1161/CIRCULATIONAHA.109.894170)

  4. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin I, John P, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Journal of the American College of Cardiology 2014 63 e57–e185. (https://doi.org/10.1016/j.jacc.2014.02.536)

    Article  Google Scholar 

  5. Treibel TA, López B, González A, Menacho K, Schofield RS, Ravassa S, Fontana M, White SK, DiSalvo C, Roberts N, et al. Reappraising myocardial fibrosis in severe aortic stenosis: an invasive and non-invasive study in 133 patients. European Heart Journal 2017 39. (https://doi.org/10.1093/eurheartj/ehx353)

  6. Treibel TA, Fontana M, Kozor R, Reant P, Espinosa MA, Castelletti S, Bulluck H, Bhuva AN, White SK, Herrey AS, et al. Diffuse myocardial fibrosis–a therapeutic target? Proof of regression at 1-year following aortic valve replacement: the RELIEF-AS study. Journal of Cardiovascular Magnetic Resonance 2016 18 O37. (https://doi.org/10.1186/1532-429X-18-S1-O37)

    Article  Google Scholar 

  7. Bhattacharyya S, Khattar R, Chahal N, Moat N, Senior R. Dynamic assessment of stenotic valvular heart disease by stress echocardiography. Circulation: Cardiovascular Imaging 2013 6. (https://doi.org/10.1161/CIRCIMAGING.113.000201)

  8. American Thoracic Society & American College of Chest Physicians. ATS/ACCP statement on cardiopulmonary exercise testing. American Journal of Respiratory and Critical Care Medicine 2003 167. (https://doi.org/10.1164/rccm.167.2.211)

  9. Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, Forman D, Franklin B, Guazzi M, Gulati MV, et al. Clinician’s guide to cardiopulmonary exercise testing in adults a scientific statement from the American Heart Association. Circulation 2010 122. (https://doi.org/10.1161/CIR.0b013e3181e52e69)

  10. Domanski O, Richardson M, Coisne A, Polge AS, Mouton S, Godart F, Edmé JL, Matran R, Lancellotti P, Montaigne D. Cardiopulmonary exercise testing is a better outcome predictor than exercise echocardiography in asymptomatic aortic stenosis. International Journal of Cardiology 2017 227. (https://doi.org/10.1016/j.ijcard.2016.10.070)

  11. Dulgheru R, Magne J, Capoulade R, Davin L, Vinereanu D, Pierard LA, Pibarot P, Lancellotti P. Impact of global hemodynamic load on exercise capacity in aortic stenosis. International Journal of Cardiology 2013 168. (https://doi.org/10.1016/j.ijcard.2013.01.205)

  12. Wharton G, Steeds R, Allen J, Phillips H, Jones R, Kanagala P, Lloyd G, Masani T, Mathew T, Oxborough D, et al. A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography. Echo Research and Practice 2015 2 G9–G24. (https://doi.org/10.1530/ERP-14-0079)

    Article  Google Scholar 

  13. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, et al.. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. Journal of the American Society of Echocardiography 2005 18. (https://doi.org/10.1016/j.echo.2005.10.005)

  14. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, et al. ACC/AHA 2002 Guideline Update for Exercise Testing: summary article a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002 106. (https://doi.org/10.1161/01.CIR.0000034670.06526.15)

  15. Baba R, Nagashima M, Goto M, Nagano Y, Yokota M, Tauchi N, Nishibata K. Oxygen uptake efficiency slope: a new index of cardiorespiratory functional reserve derived from the relation between oxygen uptake and minute ventilation during incremental exercise. Journal of the American College of Cardiology 1996 28. (https://doi.org/10.1016/S0735-1097(96)00412-3)

  16. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, et al.. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal 2012 33. (https://doi.org/10.1093/eurheartj/ehs109)

  17. Cioffi G, Faggiano P, Vizzardi E, Tarantini L, Cramariuc D, Gerdts E, de Simone G. Prognostic effect of inappropriately high left ventricular mass in asymptomatic severe aortic stenosis. Heart 2011 97. (https://doi.org/10.1136/hrt.2010.192997)

  18. Pellikka PA, Sarano ME, Nishimura RA, Malouf JF, Bailey KR, Scott CG, Barnes ME, Tajik AJ. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation 2005 111. (https://doi.org/10.1161/CIRCULATIONAHA.104.495903)

  19. Lancellotti P, Moonen M, Magne J, O’Connor K, Cosyns B, Attena E, Donal E, Pierard L. Prognostic effect of long-axis left ventricular dysfunction and B-type natriuretic peptide levels in asymptomatic aortic stenosis. American Journal of Cardiology 2010 105. (https://doi.org/10.1016/j.amjcard.2009.09.043)

  20. Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. New England Journal of Medicine 1990 322. (https://doi.org/10.1056/NEJM199005313222203)

  21. Salcedo EE, Korzick DH, Currie PJ, Stewart WJ, Lever HM, Goormastic M. Determinants of left ventricular hypertrophy in patients with aortic stenosis. Cleveland Clinic Journal of Medicine 1989 56. (https://doi.org/10.3949/ccjm.56.6.590)

  22. Kupari M, Turto H, Lommi J. Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure? European Heart Journal 2005 26. (https://doi.org/10.1093/eurheartj/ehi290)

  23. Dweck MR, Boon NA, Newby DE. Calcific aortic stenosis: a disease of the valve and the myocardium. Journal of the American College of Cardiology 2012 60. (https://doi.org/10.1016/j.jacc.2012.02.093)

  24. Barone-Rochette G, Piérard S, De Meester de Ravenstein C, Seldrum S, Melchior J, Maes F, Pouleur AC, Vancraeynest D, Pasquet A, Vanoverschelde JL, et al. Prognostic significance of LGE by CMR in aortic stenosis patients undergoing valve replacement. Journal of the American College of Cardiology 2014 64. (https://doi.org/10.1016/j.jacc.2014.02.612)

  25. Lancellotti P, Donal E, Magne J, Moonen M, O’Connor K, Daubert JC, Pierard LA. Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay. Heart 2010 96. (https://doi.org/10.1136/hrt.2009.190942)

  26. Chin CWL, Pawade TA, Newby DE, Dweck MR. Risk stratification in patients with aortic stenosis using novel imaging approaches. Circulation: Cardiovascular Imaging 2015 8 e003421. (https://doi.org/10.1161/CIRCIMAGING.115.003421)

    Google Scholar 

  27. Lancellotti P, Donal E, Magne J, O’Connor K, Moonen ML, Cosyns B, Pierard LA. Impact of global left ventricular afterload on left ventricular function in asymptomatic severe aortic stenosis: a two-dimensional speckle-tracking study. European Journal of Echocardiography 2010 11. (https://doi.org/10.1093/ejechocard/jeq014)

  28. Pibarot P, Dumesnil JG. Improving assessment of aortic stenosis. Journal of the American College of Cardiology 2012 60. (https://doi.org/10.1016/j.jacc.2011.11.078)

  29. Kearney LG, Lu K, Ord M, Patel SK, Profitis K, Matalanis G, Burrell LM, Srivastava PM. Global longitudinal strain is a strong independent predictor of all-cause mortality in patients with aortic stenosis. European Heart Journal: Cardiovascular Imaging 2012 13. (https://doi.org/10.1093/ehjci/jes115)

  30. Yingchoncharoen T, Gibby C, Rodriguez LL, Grimm RA, Marwick TH. Association of myocardial deformation with outcome in asymptomatic aortic stenosis with normal ejection fraction. Circulation: Cardiovascular Imaging 2012 5. (https://doi.org/10.1161/CIRCIMAGING.112.977348)

  31. Nagata Y, Takeuchi M, Wu VC-C, Izumo M, Suzuki K, Sato K, Seo Y, Akashi YJ, Aonuma K, Otsuji Y. Prognostic value of LV deformation parameters using 2D and 3D speckle-tracking echocardiography in asymptomatic patients with severe aortic stenosis and preserved LV ejection fraction. JACC: Cardiovascular Imaging 2015 8. (https://doi.org/10.1016/j.jcmg.2014.12.009)

  32. Magne J, Cosyns B, Popescu BA, Carstensen HG, Dahl J, Desai MY, Kearney L, Lancellotti P, Marwick TH, Sato K, et al. Distribution and prognostic significance of left ventricular global longitudinal strain in asymptomatic significant aortic stenosis: an individual participant data meta-analysis. JACC: Cardiovascular Imaging 2019 12. (https://doi.org/10.1016/j.jcmg.2018.11.005)

  33. Yu C-M, Sanderson JE, Marwick TH, Oh JK, Doppler T. Imaging: a new prognosticator for cardiovascular diseases. Journal of the American College of Cardiology 2007 49. (https://doi.org/10.1016/j.jacc.2007.01.078)

  34. Nikitin NP, Witte KK. Application of tissue Doppler imaging in cardiology. Cardiology 2004 101. (https://doi.org/10.1159/000076694)

  35. Poulsen SH, Søgaard P, Nielsen-Kudsk JE, Egeblad H. Recovery of left ventricular systolic longitudinal strain after valve replacement in aortic stenosis and relation to natriuretic peptides. Journal of the American Society of Echocardiography 2007 20. (https://doi.org/10.1016/j.echo.2006.11.020)

  36. Lancellotti P, Lebois F, Simon M, Tombeux C, Chauvel C, Pierard LA. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation 2005 112 I377–I382. (https://doi.org/10.1161/CIRCULATIONAHA.104.523274)

    Article  Google Scholar 

  37. Rajani R, Rimington H, Chambers JB. Treadmill exercise in apparently asymptomatic patients with moderate or severe aortic stenosis: relationship between cardiac index and revealed symptoms. Heart 2010 96. (https://doi.org/10.1136/hrt.2009.181644)

  38. van Zalen J, Patel NR, Podd SJ, Raju P, McIntosh R, Brickley G, Beale L, Sturridge LP, Lloyd GWL. Prognostic importance of tissue velocity imaging during exercise echocardiography in patients with systolic heart failure. Echo Research and Practice 2015 2. (https://doi.org/10.1530/ERP-14-0074)

  39. McIntosh RA, Silberbauer J, Veasey RA, Raju P, Baumann O, Kelly S, Beale L, Brickley G, Sulke N, Lloyd GW. Tissue Doppler-derived contractile reserve is a simple and strong predictor of cardiopulmonary exercise performance across a range of cardiac diseases. Echocardiography 2013 30. (https://doi.org/10.1111/echo.12084)

  40. Maréchaux S, Hachicha Z, Bellouin A, Dumesnil JG, Meimoun P, Pasquet A, Bergeron S, Arsenault M, Le Tourneau T, Ennezat PV, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. European Heart Journal 2010 31. (https://doi.org/10.1093/eurheartj/ehq076)

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Authors and Affiliations

  1. Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK

    Jet van Zalen PhD, Lesley M. Hart HTEC BSE, Andrew J. Marshall MD MRCP & Nikhil R. Patel MBBS FRCP

  2. Centre for Sport and Exercise Science and Medicine (SESAME), University of Brighton, Eastbourne, UK

    Jet van Zalen PhD, Louisa Beale PhD & Gary Brickley PhD

  3. Barts Heart Centre, St. Bartholomew’s Hospital, London, UK

    Jet van Zalen PhD, Sveeta Badiani MRCP, Sanjeev Bhattacharyya MD MRCP FESC & Guy W. Lloyd FBSE MD FRCP

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  1. Jet van Zalen PhD
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van Zalen, J., Badiani, S., Hart, L.M. et al. The importance of contractile reserve in predicting exercise tolerance in asymptomatic patients with severe aortic stenosis. Echo Res Pract 6, 43–52 (2019). https://doi.org/10.1530/ERP-19-0005

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